Tricuspid Regurgitation (TR)

Grade it with echo - Doppler echocardiography is the primary tool. It maps the regurgitant jet and its velocity, estimates RV systolic pressure, and shows annular dilation, leaflet tethering, and RV size and function.

Read the ECG for right heart strain - right axis deviation with tall R waves in V1 to V2 suggests RV hypertrophy from pulmonary hypertension, P-pulmonale points to right atrial enlargement, and nonspecific ST and T changes in the right precordial leads reflect RV dysfunction.

Send a hepatic panel - passive congestion from chronic right-sided failure shows up as abnormal LFTs and hyperbilirubinemia. Cardiac catheterization in the same patient shows elevated right atrial and RV end-diastolic pressures, and that central venous hypertension is what congests the liver.

Pulmonary hypertension is the usual driver - anything that raises RV pressure or volume dilates the annulus and widens the regurgitant orifice, so protecting the RV means keeping PVR down. Inhaled nitric oxide is the pulmonary vasodilator used for this.

Regurgitation is phasic - TR severity rises with inspiration as the RV widens and enlarges the annulus, so the regurgitant fraction and the hemodynamics swing with the respiratory cycle.

Volume balance - loop diuretics and sodium restriction are the medical mainstay for congestion, and head-up positioning improves dyspnea. Overshooting drops preload the volume-loaded RV still depends on.

Expect atrial arrhythmias - a dilated right atrium fibrillates, and antiarrhythmic therapy is started when it does. In Ebstein anomaly, atrial fibrillation, atrial flutter, or ectopic atrial tachycardia occurs in 25% to 65% of patients.

Know the hardware - permanent pacing and ICD leads crossing the valve restrict leaflet motion and can themselves cause TR or tricuspid stenosis. Restricted leaflet mobility from implanted leads also excludes a patient from transcatheter repair.

Valve choice - bioprostheses are usually chosen in the tricuspid position because of the low pressures, the thrombotic risk, and the likelihood of future pacemaker leads. Mechanical tricuspid prostheses carry thrombotic risk and need regular INR monitoring.

TEE in the room - three-dimensional TEE is required to steer and place transcatheter tricuspid clips, and it outperforms TTE for defining leaflet anatomy and detecting intracardiac shunts before surgery.

Tricuspid regurgitation (TR) is systolic backflow from the right ventricle into the right atrium. Most adult TR is secondary: the leaflets are anatomically normal, but RV pressure or volume overload dilates the annulus and tethers the leaflets so they stop coapting. Pulmonary hypertension, RV ischemia, cardiomyopathy, and left-sided valve disease drive that dilation. Primary TR is less common - endocarditis, rheumatic disease, Ebstein anomaly, or pacemaker and ICD leads fouling the valve apparatus.

Mild to moderate TR is well tolerated because the right atrium is compliant. Severe TR produces RV volume overload and right-sided heart failure: distended pulsatile neck veins, painful hepatosplenomegaly, ascites, peripheral edema, and falling cardiac output. Regurgitation worsens during inspiration, when the RV and annulus widen and the effective regurgitant orifice grows.